Botox and Fillers for Marionette Lines Beginning to Show?

I am 44 but have been doing Thermage, Refirme ST, and Microcurrent for several years periodically. I have no wrinkles anywhere now except the very slight beginnings of a depression where marionette lines will form (my mom has them terribly). Will fillers work? i have had fillers migrate to other areas before. How do I know what to inject and who to have inject? I am really worried since I have had filler issues in the past. Could Botox help in minimizing the smile muscle at the corners of my mouth right beneath the bottom of the nasolabial fold? I would love specific advice. Thanks!

Doctor Answers 7

It might be safer for you to wait

It is always a concern when addressing minimally obvious features as there may not be enough improvement for you to be happy, and more risk in having the product / filler be more visible if your slight marionette depressions were to be filled. Local movement during injection or with your muscle movement during eating or speech could move the product into the adjoining areas without migration to distant sites. So unless you are very bothered by these slight depressions, it might be safer for you to wait longer before you have them treated. Wait for them to be more obvious. Botox can be injected in the lower outer chin area near the jawline to help lift the corner of the mouth which might be different than that what you are seaking. Other areas around the mouth are more dangerous to inject as when these muscles get affected, there might be a droop of the lip or a failure ot close the loop. This could look like someone had a stroke! Question your friends to see who they use and ask your doctors for a referral.

Manhattan Dermatologic Surgeon
4.9 out of 5 stars 38 reviews

Yes to both

The best way to address your problem is with Botox into the mentalis and DAO, and filler into the marionette and pre-jowl sulcus. Issues with poor results from filler are usually traced back to less experienced (and even unqualified) injectors.

I have even given an entire lecture entitled: It is not the filler (the product), but the Filler (the person injecting) that makes the difference.

Be sure your doctor is board certified IN AN APPROPRIATE SPECIALTY, like dermatology and plastic surgery. There are a lot of imposters out there, so do your homework. Board certified means you have been trained in an accredited residency program and been invited to be tested. If you then PASS the test, you are board certified in that specialty. Only board certified dermatologists can be FELLOWS, of the American Academy of Dermatology.

Mary P. Lupo, MD
New Orleans Dermatologist
5.0 out of 5 stars 18 reviews

I like a combination of Botox and fillers for the oral commissure

The area you are describing is loosely referred to as the oral commissure that forms the "beginning" for the Marionette line that can start there and "travel" vertically downward on the lateral chin. This can be a very challenging area and I have found that a "combination therapy" works well in this area.

Often the patients have some loss of volume and this shows as a dimple or dimple with line. Many times, the lips have some deflation as well and there is "downturning" of the actual anatomic oral commissure (where the lips come together at the side). If the lips have significant deflation it is reasonable to consider adding some volume to them as well for proper facial balance and harmony.

Something I have quite a bit of experience with is Botox injections into the DAO (Depressor Anguli Oris) muscle which can elevate the oral commissures. Doing this in combination with a filler can give a great result, essentially lifting and filling the corners of the mouth. I have found success with both Perlane, Restylane, and Juvederm but another excellent option for filling this area and achieving even longer lasting results is Radiesse.

I hope this helps!

James F. Boynton, MD, FACS
Houston Plastic Surgeon
4.8 out of 5 stars 42 reviews

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Fillers work well for marionette folds.

Dear Smag,

If you email / post a picture, I'd be happy to give you specific advice.

Injectable fillers are great for filling in all types of folds, especially at the corners of the mouth. The type of filler you choose should be based on the experience and advice provided by your doctor. Consulting a board certified facial plastic surgeon or dermatologist is a good place to start.

Botox has been described as being helpful in elevating the corners of the mouth. If your doctor is experienced and confident with that application, then go for it.

Lastly, injectable fillers do not migrate when used properly. I'd be interested to learn what issues you've had in the past.

I hope this is helpful, and best regards.

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 421 reviews

Marionette region

Botox may indeed have a place for reducing the activity of the DAO (depressor anguli oris) muscle, the frown muscle of the lower lip.

In addition, cleverly placed hyaluronic acid filler in the marionette and lateral lip region can also reduce the appearance of the marionette folds.

I would urge patients to avoid semipermanent fillers. We have seen many cases of chronic swelling, even with Radiesse, causing disfigurement requiring revision surgery. Since elements of the filler are permanent, this disfigurement is unfortunately only partially treatable. If a patient should have an untoward swelling reaction from a hyaluronic acid filler, on the other hand, this can be reversed with hyaluronidase.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 178 reviews

You may not need any treatment yet.

Hi! Remember, fillers are not meant to be preventive. It is not clear that you have marionette lines yet.

When you do, in New York, we would probably treat you with Restylane injections. I don't think Botox has a role.

See a board certified plastic surgeon or a board certified dermatologist.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 reviews

Botox and fillers may both be beneficial for marionette lines.

It is possible that Botox into the depressor anguli oris muscle may soften the downturning at the oral commissure and the inferior most extent of the nasolabial fold.

Fillers are probably more effective for this area. I would initially employ a hyaluronic filler. Consider Restylane or Juvederm. If you do not like the results, you can always partially reverse the effects using off-label hyaluronidase

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 82 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.